Introduction 1 CHAPTER I INTRODUCTION

Transcription

1 Introduction 1 CHAPTER I INTRODUCTION World Health Organisation (W.H.O.) projected an increase of diabetes which has already reached epidemic proportions, particularly in urban India. Possibly by the year 2025, India shall have approximately 57.2 million diabetics, the maximum number of diabetics in any one single country. That s about the size of the population of Great Britain or France. The term Diabetes Mellitus was derived from the Greek words meaning, passing through and sweet as honey. Ancient Ayurvedic physicians some 3000 years back recognized polyuria with sweet tasting substance in the urine. The urine of polyuric patients (prameha) was first described by two notable Indian physicians Sushruta and Charaka as tasting like honey, being sticky to touch and strongly attracting ants. Different types of diabetes 1. Type I IDDM/Juvenile onset DM 2. Type II NIDDM/Maturity onset D.M 3. IGT Impaired Glucose Tolerance 4. Gestational Diabetes 5. Other types Diabetes associated with certain condition and syndrome such as drug induced or chemical, secondary to pancreatic disease, secondary to Endocrine disease.

2 Introduction 2 Characteristic of Insulin dependent and Non-Insulin Dependent diabetes Insulin-Dependent (Type I) Non Insulin Dependent (Type-II) Age of onset Usually during youth, butcan occur at any age Usually during adulthood: more common in older people How noticed Usually appears abruptly and progresses rapidly Gradual in onset; the disease may go unnoticed for years Family background Diabetes not always present in other family members Often diabetes was present in other members of the family Treatment Insulin injections are Insulin injections are not necessary- Diet, always necessary. Oral exercise, and emotional control are Necessary medications are sometimes recommended. Diet, exercise, and emotional control are necessary Complications Problems affecting blood vessels, eyes, kidneys, and nerves may occur at Problems affecting blood vessels, eyes, kidneys, and nerves may occur at any age any age Linked to obesity Not necessarily 80 percent of all patients are overweight at time of diagnosis.

3 Introduction 3 IGT Impaired Glucose Tolerance : In 1980, the WHO expert committee first defined IGT as a metabolic state between normal and diabetes, and as a high-risk group for diabetes and cardiovascular disease (CVD). People with IGT have blood glucose levels that are higher than normal but not yet diabetic. This condition is diagnosed using the oral glucose tolerance test (OGTT). After a fast of 8 to 12 hours, a person s blood glucose is measured before and 2 hours after drinking a 75 grm glucose containing solution. Long term populations studies have shown that as the fasting and 2 hr 75 gm Post prandial glucose level rises, so does the incidence of complications. However at a level of fasting glucose >125 or a PP level of > 180 to 200mg%, the complication rate increases disproportionately. Hence those levels were recognized on the level at which to diagnose the onset of Type II D.M. This is shown in the figure below In normal glucose tolerance, blood glucose rises not higher than 140 mg/dl 2 hrs after the drink. In impaired glucose tolerance IGT, the 2 hr blood glucose is between 140 and 199 mg/dl. If the 2 hr. blood glucose rises to 200 mg/dl or above, a person has diabetes.

4 Introduction 4 Subsequent epidemiological studies suggest that at a fasting blood glucose level exceeding 100 mg%, the rate of macrovascular complications increase faster and at a level above 110 mg%, the rate microvascular complication also rises. Hence, some authorities today profer to consider 100 mg% as the cutoff point for normal fasting blood glucose. As few as 1 to as many as 10 out of every 100 person with IGT will develop diabetes every year. The risk of getting diabetes rises as people become more over weight and have more sedentary lifestyle, have a stronger family history of diabetes, and belong to a racial or ethnic minority group. Diabetes Prevention Program (DPP) is a clinical study sponsored by the National Institute of Diabetes, Digestive and Kidney Disease in USA have already demonstrated the potential of lifestyle intervention or pharmacological treatments for the prevention or delay of Type II Diabetes in subjects with impaired glucose tolerance (IGT). Glucose concentration value chart (mg per ml of blood) Normal a) Fasting value b) 2 hrs. after meals Impaired Glucose Tolerance* a) Fasting value b) 2 hrs. after taking glucose Diabetes Mellitus** a) Fasting value 125 b) 2 hrs. after taking glucose Source : WHO * These values are the boarderline cases of mild high blood sugar and can be recommended for further investigations/tests by the doctor so that the person with such condition should take necessary precaution to control it in time. ** Stands for equal to and greater than.

5 Introduction 5 Sushruta described two groups one as congenital (sahaja) IDDM and the other due to injudicious way of life (Apathyaja) NIDDM Charaka also mentioned two types of Diabetes (prameha) one stout and strong (Sthula Prameha) and the other emaciated and weak (Krisha Prameha) Newer investigation tools, recent therapies have improved clinical course of diabetic. Control over blood sugar level is not a matter of problem today. But, even today, to understand metabolism and treatment of diabetes mellitus requires a demanding and spectrum of knowledge about chemical, immunological, vascular, histopathological and endrocrine factors in human. The control of complication is still a challenge for physicians of present era, as complications do appear or do progress even after proper control of blood sugar level in a diabetic person. Chronic Complications of Diabetes Mellitus Microvascular Macrovascular Other Eye disease Retinopathy (Nonproliferative/ proliferative) Macularo edema Cataract Glucoma Neuropathy Sensory and motor (mono and polyneuropathy) Autonomic Nephropathy Coronary artery disease, Peripheral vascular disease, cerebrovascular disease Gastrointestinal (Gastroparesis Diarrhoea) Genitourinary (Uropathy/Sexual dysfunction) Dermatological Metabolicketoacidosis, Hyperglycemic hyperosmolor nonketotic coma, Hypoglycaemia

6 Introduction 6 Peripheral symmetric sensomotor neuropathy cranial and peripheral motor neuropathy. (Electrophysiological) studies demonstrate subclinical abnormalities, including slowed motor and sensory nerve conduction in most patients after 5 to 10 years of diabetes. Distal symmetric sensorimotor neuropathy detectable on physical examination is only minimally bothersome for most patients. Symptoms including paresthesia are characteristically worse at night. Loss of sensation in the feet and altered foot architecture make foot problematic. The principal risk posed by peripheral neuropathy is of foot trauma and diabetic ulcer.

7 Introduction 7 Diabetic foot disease (ulcer/gangrene) is one of the most frequent cause of hospitalization and is one of the expensive complications of diabetes (Rayappa PH et al., 1999). An alarming fact is that among people with diabetes, 15% will experience foot ulcer in their lifetime and patients with such foot ulcers go on to need an amputation (Pendseys 2003). On an average in every 20 minutes one diabetic foot amputation is undertaken in India. World Health Organisation has defined Diabetic foot as Lower limb of a diabetic patient that has the potential risk of pathological consequences, including infection, ulceration or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular diseases and/or metabolic complications of diabetes. A diabetic without foot problem spends 9.3% of his income on his illness whereas a diabetic with foot problems spends 32.3% of his income on his illness (Ramchandran A 2005). It is a severe on socioeconomical burden on the country. The present study is conducted with a view to understand genesis of diabetic foot with special reference to ancient Ayurvedic concept and to carry out study on herbal drugs in its management which is cost effective aiming to save the affected foot and provide the patient a functional walkable foot, as amputation does not appear to practical solution for management of diabetic foot in a country like India where good prosthetic facilities are either not available or not affordable.